Chronic Pain and Sleepless Nights

A vicious cycle: Chronic pain and sleepless nights cause more insomnia andf atigue.

Chronic pain is technically considered persistent discomfort lasting more than three to six months. It might only occur from time to time, or it can be continuous. Chronic pain can last for months, or it can last for a lifetime. It tends to interfere with various aspects of normal daily living, like mobility, concentration, socialization, and work, among other things. There are so many causes: Injury, arthritis, cancer, accidents, fibromyalgia, or maybe just wear and tear on muscles, bones, and joints that are just "normal" for an aging body. To deal with this day after day can be downright exhausting.

There are plenty of reasons why chronic pain causes fatigue: Sleeping difficulties often arise where a lack of sleep causes pain centers in the brain and neurons to become snsitive and hyperactive, creating more pain. The pain, in turn, makes it even more difficult to sleep. That's a vicious cycle. Pain also increases chemicals in your body, for example, cytokines, that go to the area of pain to decrease inflammation. Cytokines often increase fatigue. Dealing with pain and lack of sleep can be both physically and emotionally taxing, causing undue stress, anxiety, and depression, which all increase fatigue and...often lack of sleep.

Pain and Fatigue

Treatment and Alternative Approaches to Pain

Treating fatigue related to chronic pain is aimed at alleviating the underlying cause of the pain or changing the perception of it. Once the pain is gone or a person learns to cope with it, a lot of fatigue will theoretically be gone. 

​More and more options are being developed to target specific sources of pain, like nerve pain and arthritic pain. There are also pain specialists who focus only on pain control. So, if you suffer from chronic pain, explore different options with your healthcare provider. If you hit a dead end, and you are at your wits' end, see a pain specialist. They help diagnose and treat many types of pain.

The following are different approaches you can take to relieve pain:

• Ice Packs (usually initially for the first 48-72 hours) Use for 15 minutes about 3 times a day. Note: Be sure to wrap the ice because direct application to the skin for more than a few minutes can cause damage to and even frostbite in some cases.

• Heat (Warm moist heat - 15 minutes, about 3 times a day)

• Hydration

• Try relaxation and meditation techniques:

  -Deep breathing exercises - This helps release endorphins in your brain, which are"feel good" hormones. This technique is practiced by taking a deep breath through your mouth using your diaphragm muscle located just beneath your lower ribs (instead of using neck, shoulder and upper chest muscles), pausing and then releasing the breath through the mouth. Repeat this several times.

  -Guided Imagery - Think of a relaxing situation or a place you have been and focus on only that - focusing on texture, smells and visuals.

  -Mindfulness - This is when a person focuses on the present moment, feeling and experiencing the moment with awareness and acceptance, not judgment. This reportedly helps the fronto-limbic area of the brain, which is responsible, in great part, for emotional regulation and processing.

  -Progressive Muscle Relaxation Exercises: This is done by tightening muscle groups for eight seconds then relaxing them for several seconds: Begin with facial muscles, with the face, moving to the scalp - tighten muscles eight seconds, then relax; then the neck, doing with each muscle group of the chest, back, pelvis, extremities and so on. This releases some tension and stress. If you do not have time to move through all of your muscle groups, do this with those muscles you believe have the most tension.

  -Analytical Meditation - This meditation involves focus on an object or a concept and focusing on only that.

  -Body Scanning-Focus on a part of your body and feel relaxation, warmth, release of tension

• Yoga

• Tai Chi

• Counseling (to learn methods to help tolerate pain more effectively)

• Appropriate exercise

• A healthy diet (an anti-inflammatory diet that particularly recommends that you eliminate processed and ultra-processed foods)

• ​Pain clinics help diagnose pain and take a holistic approach to treatment and care. In addition to diagnosing painful conditions, these clinics have providers who prescribe medications, give injections, provide physical therapy, occupational therapy, and utilize other approaches to pain, like cognitive behavioral therapy (psych), to help alter the perception of and tolerance to pain. A pain clinic is an ideal approach to hard-to-control chronic pain.

• Hydrotherapy and/or warm baths with Epsom Salts

Over-the-Counter Medicines

​​There are many, many causes of pain and types of pain. Some respond to very specific medications. For example, muscle or simple joint pain and some headaches may respond to over-the-counter or simple prescription anti-inflammatories, while others, like autoimmune diseases, respond to immunomodulators like methotrexate or biologics made from living organisms (which often work but are very expensive). 

Words of warning: Many medications, when used for pain on a regular basis, can also have some troublesome side effects over time.

​Please note: If there is any questions about the dosages of the following over-the-counter medications, ask a pharmacist or your healthcare provider for clarification and read all of the instructions on the containers.

NSAIDS (non-steroidal anti-inflammatories) include Ibuprofen (common: Motrin, Advil), Naproxen (common: Aleve), and acetylsalicylic acid (common: Aspirin) and are quite effective in decreasing pain in many cases. They are usually the first-line medications - the ones to start with - when you are having pain, especially pain from inflammation (almost all pain has some element of inflammation). BUT on a long-term basis, these medicines can cause gastric ulcers and bleeding as well as kidney and blood pressure issues. So, beware: alternate your pain medications if possible (for example, alternate NSAIDS like ibuprofen with a non-NSAID medication, like Tylenol, or a different prescription medication altogether). You might consider taking a stomach acid-reducing medicine (common: omeprazole/Prilosec or famotidine/Pepcid and others) while taking NSAIDs. Also remember: Aspirin thins your blood and can make you bleed more easily. Speak to your PCP about concerns you may have.

There is now a combination product that has both ibuprofen and acetaminophen in it (Advil Dual Action), which makes a lot of sense, seeing that they both work in different ways.

Naproxen is also an anti-inflammatory (common: Naprosyn). Use it as directed over the counter (see dosage information on Drugs.com). The advantage of this anti-inflammatory is that you can take it every 8 hours (or every 12, depending on how you dose it). It is also a fever-reducer.

Over-the-Counter Painkillers: Acetaminophen (common: Tylenol). Tylenol works differently from anti-inflammatories because it stops pain transmission in the nervous system. It doesn’t work to reduce inflammation. It is also a fever reducer. This is also a good medication but used long term, can cause liver problems. Again, consider alternating this with ibuprofen every few weeks or speak to your PCP about getting another prescription pain medication.

Topical Pain Relievers

• Menthyl salicylate (an anti-inflammatory related to aspirin)

• Voltaren/diclofenac

Considered Herbal and Other Natural Remedies

• CoQ10

• Curcumin

• Glucosamine

• Ginger

• Boswellia

• Peppermint

Common Prescriptive Treatments Used for Pain

• Cox-2 inhibitors (common: celecoxib (Celebrex), meloxicam (Mobic) are also nonsteroidal anti-inflammatories (NSAIDS). This medication is less likely than ibuprofen (and other NSAIDS), to cause stomach problems; however may increase the risk of cardiovascular disease if used long-term.

• Opioids (short course) - These are painkillers such as oxycodone or hydrocodone (combo opioids with Tylenol: Lortab, Percocet, and Vicodin) and Tramadol (i.e. Ultram).Be cause these are highly addictive, they are not the drug of choice for long-term pain. Try to avoid using it for recovering opioid addicts.

• Steroid injections - These injections, given at the site of a joint problem, can reduce swelling and inflammation

• Antiseizure medications: Gabapentin, Pregabalin (Lyrica for nerve pain/neuropathy)

• Antidepressants (just because you take a medicine labeled "antidepressant doesn't mean you are depressed! These are frequently used for some pain syndromes and help alter neurotransmission signals in pain) - duloxetine/Cymbalta (SNRI) and amitriptyline (antidepressant)

• Muscle relaxers (common: cyclobenzaprine, methocarbamol) 

• Anti-inflammatories: High dose ibuprofen (800 mg) is prescription

• Corticosteroids, like prednisone and dexamethasone, have lots of potential side effects, from ulcers to diabetes, to hypertension to insomnia, and sometimes downright psychosis, but they are great anti-inflammatories. Sometimes healthcare providers prescribe a low dose to use over the long term, but because of the potential side effects, it is good to look at some of the alternatives.

• ​DMARDS (common: Methotrexate) and biologics generally work well to suppress your immune system if you have an autoimmune disease. However, you have to be very careful: Since your immune system is lowered, you are at a risk of contracting an infectious illness more easily. It can be a trade-off. If you are taking this medication, try to stay away from crowds and sick people (especially kids).

Remember this: If you treat pain when it first comes on, it is easier to reduce and stop the pain. That is, treat early.

Explore different causes of pain and approaches to pain relief:

• Arthritis

• Fibromyalgia

• Lupus

• Pain from a viral or bacterial illness

• Knee pain

• Musculoskeletal Injuries

• Low Back Pain

• Gout

• Neuropathic Pain

• Pain From Stress and Tension

Treatment and Alternative Approaches to Sleep

Consider using these alternative approaches to sleep:

• Read or listen to music.

• Try massage, acupuncture, meditation, yoga, tai-chi, relaxation techniques, and journaling (surprisingly, how much this can help).

• Exercise. This increases endorphins (the feel-good neurotransmitters) and decreases stress hormones (adrenaline and cortisol), so you feel happier and more relaxed.

• Sleep - Try to get enough sleep (7-9 hours). Make sleep a routine and ritual if you can. Make your sleep area a nice and comfy place. A dark, quiet, and cool bedroom is often recommended. Most sources recommend that you do not sleep too much either as it may disrupt the sleep cycle by affecting melatonin activity (a hormone that regulates sleep).

• Eat nutritious/anti-inflammatory meals. It’s not just the foods you eat but how you eat them! Eat healthy meals: Try to stick to mainly protein and fiber; Things like nuts, seeds, almonds (and “butters” made from these), chia seeds, whole grain bread, Greek yogurt, spinach (for those of you who remember Popeye), eggs, salmon, lean meat, oatmeal, berries, sweet potatoes, beets, oranges, and others. Try to eat several small meals a day. Why? Because a big meal does a couple of things: It causes a spike in blood sugar, which will give you a brief pick-me-up, but suddenly the sugar drops and makes you feel more tired. You also use more energy to digest a lot of food – more blood flows to your digestive tract, away from the rest of your body. A greater release of hormones, like serotonin, causes more relaxation (which is good), but it also causes fatigue. 

• Stay well-hydrated

• Hydrotherapy

• Take time to connect with a support system—whether it's family, friends, or even a counselor. Sometimes, you just need to sort things out.

​Over-the-Counter Medications

• Multivitamin supplements: Especially vitamins C, B, D, magnesium, zinc, folic acid and iron as supplementation for menstruating women to help increase energy.

• ​Melatonin to help sleep (as directed over-the-counter: Start with a lower dose)

• Control pain​

Considered Natural Remedies for Fatigue

• L-tryptophan to help with sleep-related fatigue

• L-Carnitine

• CoQ10 for energy

• 5-HTP for sleep-related fatigue

• Lemon balm for sleep-related fatigue

• Valerian for sleep-related fatigue

• Ginseng for energy

• Ashwagandha for energy

• Rhodiola for energy

• Sage for energy

• Ginkgo biloba for energy

• Peppermint for energy

​Prescriptive treatment 

• Treat underlying anxiety and depression

• For sleep problems: Try Zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Lunesta), and others (these are all controlled, potentially addictive medications, with possible side effects when used long-term and short-term, but they do work for insomnia). They can often help you sleep through much of your pain. Be careful using these with narcotic pain medications.

• Low-dose neuroleptics for sleep (common: Trazodone and Seroquel) are off-label (not FDA approved) for sleep but are used often and reportedly work well for insomnia.

• Serotonin-norepinephrine reuptake inhibitors, which can help reduce pain and energize during the day (common: Cymbalta, Bupropion/Wellbutrin)

A person does not have to live with chronic pain and sleepless nights. If you can manage these problems without medicines, all the better. But that is not always possible. If you continue to struggle with this, contact to a healthcare provider or a pain specialist who can give you further guidance.